Author(s): * Dr Sona Bedi, ** Dr Sanjay Arya, *** Prof RK Sarma

Vol. 16, No. 1 (2004-01 - 2004-06)

Abstract

With the healthcare market turning from a sellers market into a buyers market, healthcare providers are turning more and more towards marketing of their services. This requires a marketing information system, which provides information that is accurate, timely and need-based. Market research can provide such information to hospital administrators. For this, a relevant tool for hospital administrators today is a patient expectation survey, which reveals what patients actually desire from hospitals. Patient satisfaction has been found to be a desired outcome in hospitals. When results of such patient expectation surveys are applied to planning of healthcare services, it increases chances of achieving patient satisfaction.

Introduction

As we enter the 21 st century, changes are apparent and indeed desirable in our attitudes and mindset. Old practices give way to new ones and hospital administrators in contemporary times are not untouched by all this. Slowly, but surely, the healthcare market is changing from being primarily a sellers' market to being a buyers' market. A beginning in this direction has been made in the developed countries by the now well evolved system of managed care. Grabbing a lion's share of the healthcare market in the future will be the aim of many a healthcare organisation in India as well. Other than clinical excellence, healthcare providers now recognise the presence of other factors playing a role in the share-capturing game. The realization of the need for marketing in hospitals has gained momentum in recent years. Rapidly changing developments in the healthcare field will see more emphasis being placed on marketing of hospital services. A hospital's success will depend more and more on strategic planning based on timely and accurate information1

Market Research and Market Information Systems in Healthcare

Marketing activities are designed to create value in planning, organising, pricing and delivering healthcare services. Marketing is defined by Philip Kotler as “a social & managerial process whereby individuals and groups obtain what they need and want through creating and exchanging products and value with others”2. Another definition of marketing by American Marketing Association is “process of planning & executing the conception, pricing, promotion & distribution of ideas, goods and services to create exchanges that satisfy individual and or organisational goals”. Some of the key terms in the above definitions include Value, Satisfaction and Quality. Customer value is the difference between values the customer gains from owning and using a product and the costs of obtaining the product. A more important concept for us is customer satisfaction, which is the extent to which a products' perceived performance matches a buyers expectations. If perceived performance falls below the buyer's expectations, customer is dissatisfied, but if perceived performance matches customers' expectations, buyer is satisfied. However, if perceived product performance exceeds customer expectations, buyers are delighted. A need for developing a system to identify such expectations is therefore felt.

Market Information System is a continuing and interacting structure of people, equipment and procedures to gather, sort, analyse, evaluate and distribute needed, timely and accurate information to marketing decision makers. One part of MIS is Market Research, which implies systematic design, collection, analysis and reporting of data relevant to a specific marketing situation facing an organisation3. This is equally relevant for hospital administrators, as timely, accurate and adequate information is a prerequisite for making marketing decisions regarding delivery of hospital services. One of the Market Research tools helpful in addressing this issue is a Patient Expectation Survey (PES). This could be an initial marketing activity of an upcoming hospital or could also be an ongoing process in response to a certain problem being faced by the hospital. A patient expectation survey may also be included in the hospital's Customer Relationship Management (CRM) activities.

The Issue of Quality

Another key term in marketing is Quality. Quality has various definitions, and in the narrowest sense means ‘freedom from defects'. However, American Society for Quality Control defines quality as ‘totality of features and characteristics of a product or service that bear on its ability to satisfy customer needs.' Even ‘six sigma'-the current highest level of achievable quality, is measured in terms of number of defects per million parts. But as far as the service industry is concerned, what is a defect? Some organisations believe that ‘anything that does not satisfy the customer is a defect'2. Patients nowadays are more aware and more quality conscious than before. So, it stands to reason that a high level of quality, which can translate into patient satisfaction and hence profitability is important for a hospital. A very good method for ensuring this would be a patient expectation survey.

Expectancy-Disconfirmation Paradigm Model: the relation between expectation and satisfaction

If patients are viewed as consumers, a consumer model such as Expectancy- Disconfirmation model from marketing theories (Fig. 1) can be applied to healthcare provision. In this model (Fig. 2), the assumption is that patients have expectations when they visit a hospital. These expectations arise from prior experience or word-of-mouth communication, third party information or cultural milieu. The degree to which these expectations are fulfilled can be measured and there is a relationship. The higher the perceived fulfilment of expectation is higher is the satisfaction. When fulfilment is lower than expectation, the lesser is the satisfaction. When expectations are low, they are easily fulfilled and satisfaction level is kept high and vice versa4, 5.

Disconfirmation of pre-consumption expectations is the key influence on consumer satisfaction.

Positive disconfirmation: performances exceed expectations

Negative disconfirmation: expectations are not met

Ceiling floor effect:

Very high expectations (ceiling) are more likely to result in negative disconfirmation and very low expectations (floor) in positive disconfirmation.

The economics of patient satisfaction

Consumer satisfaction is important to the marketer because it is generally assumed to be a significant determinant of repeat sales; positive word-of-mouth, and consumer loyalty . Worldwide studies have shown that patient satisfaction is a required outcome in a hospital6. It has also been seen that consumer satisfaction increases profitability of organisations. Just a one percent increase in satisfaction can produce up to a three percent increase in market capitalization7. It has also been found that it can cost three or four times as much to acquire a new customer than to make a repeat sales to an existing one8. However, healthcare organisations were not spending much on marketing activities until recently. It was reported by Kotler in 1987 that most healthcare organisations spend less than one and one fourth percent of their budget in recognised marketing activities, compared to ten times that amount in many industries, and that this was predicted to change. 3

Recently an increased interest in patient satisfaction studies has been observed due to an increased need for provision of quality healthcare and increasing competition among healthcare providers. Patient satisfaction is thus one of the desired outcomes of hospital care6.

The world-wide experience

Authors Lindel-Pelz examined six determinants of patient satisfaction and found that patient expectations were most important in determining patient satisfaction9. Similarly Like and Zyzanski reported that fulfilment of a patients request was directly associated with a patient's satisfaction with an encounter10. It is now well recognised that fulfilment of patients' expectations or requests is one of the key predictors of levels of patient satisfaction 11. Furthermore, international studies have shown that dissatisfaction with a physician is a good predictor of intention to change physician12. Marketing oriented organisations therefore, go to great lengths to keep their customers satisfied and delighted who make repeat purchases and tell others about it.

Evidence of such surveys exists in literature where HMO's and Managed Care organisations have undertaken such surveys. Member-based surveying is an important tool for managed care companies to discern newer and better ways in which to keep their current members satisfied, develop products that will attract new members, and to gauge changes in healthcare consumer opinion13. Results from studies conducted elsewhere also show that patient expectation and satisfaction studies were conducted to improve services being offered by a teaching hospital's family practice clinics14. Patients' desires and expectations for medical care warrant scrutiny because of their potential influence on health care use and patient satisfaction and their effects on patients' perceptions of quality of care15. A number of studies suggest that failure to identify patient expectations can lead to patient dissatisfaction with care, lack of compliance and inappropriate use of medical resources. 16.
Moreover, recent studies have indicated consumer expectations as an integral part of measuring service quality construct, such as SERVQUAL & SERVPERF17. To be able to improve on medical consumer satisfaction, the hospital needs to evaluate all issues that are of highest concern to the consumers in their rating of the hospital17.

Work on service quality by Parasuraman, Zeithaml & Berry, 1988 18 has defined expectations in terms of what customers feel they should be offered. This is also defined as a normative hope of future events by Parkash in 198419. Patient (Customer) expectations have a bearing on patient satisfaction as shown by the disconfirmation paradigm 20. Measurement of patient satisfaction is done after the main event of patient-physician interaction has taken place. It allows change or modification of situations/ service delivery afterwards. In this study it will be contended that patient expectation survey is a beneficial tool for hospitals to determine the expectations of their patients' expectations in advance and plan services in such a way that it increases the chances of patient satisfaction.

The need for patient expectation survey (referred herein as PES)

A PES allows for need assessment of services in both qualitative and quantitative terms, leading to practice of sound evidence-based management practices.

Provisioning of quality services to consumers, which fulfils expectations and therefore has a higher chance of providing satisfaction to consumers.

Health services being high on credence qualities, consumers rely more on friends' good prior experiences and reputation of a hospital for choosing a hospital than any other promotional measure. A PES therefore is a relevant marketing activity to ensure an optimum level of patient turnover by improving chances of patient satisfaction.

Benefits of a PES

Improved efficiency in marketing activities by rational and evidence-based management practices. This is expected to result in right health service offer at right price, right place, in the right milieu with right promotion and right feedback.

Cost-effective method of planning or reorganising services as compared to only patient satisfaction surveys, as PES is done prior to provisioning of services, therefore eliminating costs of experimentation13.

Improved satisfaction of target markets, as services are now as per expectations of patients

Improved chances of attraction of marketing resources such as funds, human resource, public support and governmental support.

With the above background, the following study was conducted

Aim - To conduct a patient expectation survey among patients visiting the Outpatient department of two government hospitals.

Study Setting and design

A patient expectation survey was conducted among patients visiting the outpatient departments of two government hospitals in the NCR of Delhi . The two hospitals were selected to give a wide base for conducting a survey. Outpatient Department of both hospitals was selected as setting of study as OPD is known as the shop window of a hospital, and has the maximum impact as far as repeat visits are concerned; a factor which is important to the marketer. In the context of resource crunch and rising costs, the OPD contributes to cost containment as well as revenues in a hospital, and thus is important to the hospital administrator. A total of 230 patients (n=230) were surveyed.

This survey was carried out in two phases. In the first phase, a pilot study was done among 30 patients attending OPDs of different specialties, by conducting interviews with the help of a semi-structured questionnaire containing open-ended questions. Prior verbal consent was obtained from all participants in the survey. Undertaking was given that their identity will not be revealed in any form and information gathered in this interview will be used only for academic purposes. This pilot study revealed the general expectations among patients visiting hospitals. Based on the findings of the pilot study, a structured questionnaire was constructed and used to interview 100 patients each in the two hospitals. Every 5th patient was interviewed to eliminate interviewer bias. This questionnaire contained both open and close-ended questions about what patients expected from hospitals and physicians, along with questions intended to elicit demographic and socio-economic data of respondents. The questions asked in the second phase were based on findings of the pilot study as well as factors known in literature as service quality attributes (Parasuraman et al). Other than affirmative/negative answer question, rating scale questions were also asked. Some questions may appear to be rudimentary to the experienced, but nonetheless were asked in the interview considering that there may be expectations associated with situations in which some elements of service are so self-evident to customers, that they do not think about them, or about the possibility that these might not materialize (e.g physical examination by the physician). The existence of such expectations becomes obvious when these are not realized. These are known as implicit expectations. If such expectations are not met, these cause negative surprise, causing dissatisfaction, but when these are met, they do not bring a positive surprise 23 , akin to Hygiene factors in the Two-factor theory of motivation. In order to use the data thus obtained to chalk out a marketing strategy for the two hospitals, it was realized that it is not enough to study the patient expectation analysis in isolation. It will better serve its purpose when analysed in conjunction with a performance analysis of the hospital service under consideration. Therefore a expectation-performance analysis is needed to be made for all attributes, but especially so for the attributes which are relatively more important to the patients17. Marketing/improvement strategies based on these parameters will be thus a sound evidence-based marketing strategy and not an empirically decided one. Therefore, questions regarding actual performance of these hospitals with respect to different attributes of services which were explored in patient expectation survey in these hospitals, were also asked from respondents.

Observations:

Observations of the data compiled are presented below in Table-1 & Table 2

Tertiary Hospital

13

Expectations about Doctors clinical competence/qualification

Should be specialist only

47 %

11 %

Maybe GDMO, but able to treat me

42 %

66 %

Degrees don't matter/cant judge competence

13 %

21 %

14

Rating of various attributes of hospital services in the order of importance as deemed by patients (1=most important, 5= least important)

Good Doctor (technically competent)

1 (59 %)

1 (60 %)

Physical facilities / sanitation

2 (37 %)

5 (27 %)

Treatment / medicines

3 (37 %)

4 (33 %)

Investigations

4 (42 %)

3 (40 %)

Attitude of doctors & other staff

5 (32 %)

2 (33 %)

Analysis and Discussion

There are both similarities and differences in the expectations of patients visiting both the hospitals As well as performance of the hospital. This is observed despite the fact that one hospital is a secondary level care hospital catering to a select clientele, and the other one is a tertiary level care government referral hospital.

Demographic and socio-economic factors

Among the demographic and socio-economic factors, similarity was observed in median ages of respondents in both hospitals, more males were observed visiting hospitals than females in both situations and insurance coverage of some kind was observed in both hospitals although there was a wide variation in these percentages. The most notable difference was in the literacy levels of the patient groups of the two hospitals. In the secondary hospital, 48% of respondents were matriculate or above, whereas in the tertiary hospital, 87 % were matriculate and above. 60% of the respondents were noted to be in service and 27 % were self-employed in tertiary hospital as against all salaried workers in secondary Hospital. Only 40 % respondents in tertiary hospital had some kind of insurance/reimbursement coverage and 60 % were paying out-of pocket. This then, points to a major difference in the cultural and socio-economic milieu of the patient groups of the two hospitals.

Waiting Time

Majority of patients in Secondary Hospital expected waiting time to be 30 min to 45 min (53%) as against 20-30 min by (40 %) in the tertiary hospital. The performance shows that majority of patients in both hospitals; i.e 72% in tertiary hospital and 47 % in secondary hospital had to wait for more than 1 hr for their turn.

Implication

Expectations are higher from Tertiary Hospital than secondary hospital, possibly due to the difference in socio-economic & cultural milieu of the two patient groups.

Scope of dissatisfaction is higher in Tertiary Hospital due to lower performance levels

Marketing strategy- Tertiary Hospital as well as secondary hospital need to augment services and streamline the number of patients seen per physician, so as to decrease waiting time and improve patient satisfaction, as a decrease in number of patients is not be expected/possible.

2. Consultation Time

In the tertiary hospital, 54% respondents expected Consultation Time to be 5-10 min and 40 % expected 10-20 min, whereas in secondary hospital, only 42% expected 5-10 min Consultation Time , whereas 32% expected this to be less than 5 min. As far as performance is concerned, majority of patients in both hospitals got less than 5 min as consultation time.

Implication

Expectation higher from Tertiary Hospital

Tertiary Hospital as well as Secondary hospital needs to improve consultation time duration by augmentation of services.

This study reveals that at present with the current number of consultants waiting time is more and consultation time less as compared to expectation of people. Expectations are higher from tertiary hospitals. Both hospitals need to augment services so as to meet expectations of their clientele.

3. Listen to problems & answer questions

100 % patients in both hospitals expect physicians to listen to their problems and answer their queries, as against 73% & 63% in Tertiary and Secondary Hospital who were listened to respectively and 60% and 52% patients who were answered to respectively in the Tertiary and Secondary Hospital

Implications

Potential dissatisfaction causing factor

Sensitize doctors about above in both hospitals

Here again in both hospitals, expectations were not met and this needs attention. There is need to sensitize doctors about patient expectations, which if heeded to, can improve the situation without any additional input in terms of resources

4. Physical examination by physician

100 % patients in both hospitals expected to be physically examined. But only 53% pts in the secondary hospital and 87 % in the tertiary hospital reported that a physical examination was done. Physicians might argue here that a physical examination is not necessary in every visit and this may very well be true. But this fact needs to be communicated to the patient who is expecting it nonetheless, and this will set his/her mind at rest.

Implications

Fulfillment of patient expectations in this regard in Secondary Hospital needs focus. This can easily be done by communicating these expectations to doctors.

5 . Discussion of problem with patient and explanation of treatment

About 80 % pts in both hospitals expected the physicians to discuss their problems with them. But this expectation was reported to be met by 32 % patients in Secondary Hospital and 80 % pts in Tertiary Hospital. Physicians of Tertiary Hospital thus scored higher than doctors in Secondary Hospital in this communication aspect.

Implications

Doctors in Secondary Hospital may be sensitized about this aspect for achieving a higher level of patient satisfaction.

6. Health education & dietary counseling by doctors

A factor peculiar to the North Indian mindset was chanced upon during the 1st phase of the study. This was the expectation of patients related to dietary advice, otherwise known in local language as ‘Parhez'. This particular factor was seen to be so well ingrained in the North Indian psyche, that respondents to the extent of 80% in both the hospitals, despite the vast difference in their socio-economic and cultural milieu, expected their physicians to give them specific dietary advice and health education. In complete contrast to the previous findings on communication aspects, doctors of the Secondary Hospital scored 63% in the performance analysis as against only 20% doctors in the Tertiary Hospital fulfilling expectations of patients in this regard. This may possibly be explained by the fact that physicians in Tertiary Hospital give more specialty related advice rather than general dietary advice, and leave this to be done by dieticians, as mentioned by some respondents in the 2nd phase of study. Physicians in Secondary Hospital being generalists, possibly give more general dietary advice.

Implications

Expectations of patients regarding ‘Parhez' needs to be communicated to the doctors, as to how important it may be to patients and how it can positively effect patients' psyche, resulting in higher satisfaction and better compliance to advise of doctor.

7. Reference for investigations

It was seen that 84% patients in the Secondary Hospital and all the patients in the Tertiary Hospital expected to be referred for investigations, but only 21 % patients in Secondary Hospital were referred for investigations as against all the patients in Tertiary Hospital who were referred for investigations. This may possibly be explained by the type of patients visiting the Tertiary Hospital-probably being complicated cases requiring a lot of investigations.

Implications

Nowadays, modern medicine is increasingly relying upon investigations and public have come to judge services by investigations asked for. Here doctors cannot be expected to order investigations just as patients expect, rather this information can be communicated to the doctor who in turn, can explain to patients why investigations are/not required. This will allay the anxiety of patients and result in better compliance with advice and result in improved satisfaction.

8. Attitude/behavior of doctors (empathy)

78 % respondents in Secondary Hospital expected their physician to be polite, as against 100% in the Tertiary Hospital. This expectation was fulfilled completely in case of the Tertiary Hospital, but fell far short in the Secondary Hospital where only 36% of respondents found their expectations fulfilled in this regard.

Implications

Patients expect doctors to be polite and with improved socio-economic status, this expectation becomes more explicit. If doctors are not perceived to be polite this can be a significant dissatisfier. Doctors in secondary hospital need to be counseled and sensitized on this account.

With proper feedback, there is tremendous scope of improvement in the Secondary Hospital.

9. Expectation from Physical Facilities (tangibles)

As regards the physical facilities, the majority of respondents in both hospitals, i.e 73% in Secondary Hospital and 93% in Tertiary Hospital expected to have sufficient seating arrangements, drinking water and toilets along with high sanitation levels. But the physical facilities were found adequate by only 29 % of respondents in the Secondary Hospital as against 91 % by those visiting Tertiary Hospital. Physical facilities are seemingly adequate in the Tertiary Hospital, but there is a wide scope for improvement in Secondary Hospital.

Implications

Nowadays public is highly discerning and they expect hospitals to provide clean and hygienic environment with adequate civic amenities . As our hospitals at times, lack these, public goes back dissatisfied. Hospitals need to take regular measures to upgrade facilities and match expectations.

Expectation higher from Tertiary Hospital than from Secondary Hospital as far as tangibles are concerned.

Respondents were quizzed about their expectation about a doctor's degrees/qualification vis-à-vis their competence. 47 % respondents in Secondary Hospital expected their physician to be a specialist, whereas 42% respondents said they were unable to judge a physician's clinical competence. In case of the Tertiary Hospital, 66% expected their physicians to be a specialist while 21 % said they were unable to judge a physician's clinical competence.

Implications

More and more people are demanding specialist care. Thus secondary hospitals need to have specialists in adequate number as this has a bearing on perception of the patient regarding competence of the doctor, which influences his/her overall assessment of the hospital.

As a strategy, administration may display the physician's names along with their qualifications. This will have a positive impact on the perception of the patient regarding clinical competence of the doctor.

11. Rating of various attributes in the order of importance as deemed by the patients.

Respondents were asked to rate the various attributes of hospital services in the order of relative importance as judged by them, with the most important rated as 1 and least important rated as 5. It was seen that both groups of respondents rated a ‘good doctor' as the most important attribute. Implicit in the term ‘good doctor' is one who examines them, listens to their problems, answers their questions, is empathetic, polite, offers specific advice and one who is able to cure them (technically competent). In the Secondary Hospital the number two rating was given to physical facilities and sanitation, probably due to the perception that this was lacking in the Secondary Hospital (refer to point number 10 above). However, the attitude of the physicians was more important to clientele in the Tertiary Hospital (rated 2nd) than physical facilities and sanitation (rated 5th). This could probably be explained due to the higher levels of literacy and awareness and sensitivity to this issue, and the perception of good physical facilities and high sanitation levels by a large majority of respondents. Treatment and investigations were rated almost similarly by both groups at numbers 3 and 4.

Implications

Patients in both hospitals consider good doctor with the ‘ability to cure' as the most important attribute of medical care in a hospital. Different attributes which matter most to patients are almost same, but relative importance of these is a function of background (socio-economic status) and what is available in the hospital. But the most important thing is the doctor, who should be not only be competent i.e able to treat, but also have good communication skills and is empathetic. Good environment is needed to create a right impression on the patient, and absence of the same can have a negative impact.

Marketing strategy- without technically or clinically competent doctors, a high level of patient satisfaction is difficult to achieve.

Physical facilities and sanitation rate high in patient expectations implicitly.

Discussion

Expectations vary from hospital to hospital and from one socio-economic stratum to another. Both similarities and differences are seen in the expectations of patients frequenting both hospitals . Despite the obvious difference in socio-economic strata of the target markets of the two hospitals and the difference in the stature of the two hospitals themselves, one feature stands out prominently. This is the consideration of technical competencies of the physicians or the ‘ability to cure', communication skills and empathetic attitude, as the most important attribute of medical care in a hospital, by patients in both hospitals. Therefore, any marketing strategy devised in this regard must keep in view that without right doctors (right doctor-technically competent, with sound communication skills and empathetic attitude), a high level of patient satisfaction is difficult to achieve. It is well known that some service components will have greater influence on consumers' assessment of the overall service than others. In context of medical care, the care provided by the physician probably has a strong influence on overall assessment and resultant satisfaction with care provided21. This can actually be the USP in a marketing strategy of hospitals.

In general, patients have a higher expectation from the Tertiary Hospital than secondary hospital. This may possibly be explained by a higher incidence of literacy level in patients visiting the Tertiary Hospital. Increased literacy levels generally lead to an increased demand for quality healthcare, which in this case is possibly expressed by a higher level of explicit expectations.

In particular, in both hospitals, waiting time in physicians' queues and duration of consultation time appear to be potentially dissatisfaction causing factors. Hospital administrators of both hospitals need to devise strategies to mitigate the affect of these factors. Both hospitals also need to have a strategy of improving communication skills of physicians.

Since both hospitals appear to be patronized by a particular target market, hospital administrators can devise a marketing strategy based on expectations of patients as determined by a PES. Since there could possibly be a large number of expectations, along with expectation-performance variation instances, it would be impractical for a hospital marketing manager to devise solutions for all of those. Hence, he/she will need to prioritise issues based on particular constraints facing the hospital. As a recommendation, administrators of Secondary Hospital should devise strategies keeping in mind the importance given to communication skills of doctors, physical facilities and investigations by the patients. Tertiary hospital administrators may concentrate on strategies on lessening waiting time and increasing consultation time.

Conclusion

Patient expectation survey can be considered as a pro-active marketing activity designed to have a better chance at achieving patient satisfaction . Research in expectation-performance analysis has been conducted in areas of marketing such as health care to chalk out marketing strategies22. Sufficient informationhas been elicited regarding expectations of patients from hospital services in general and outpatient department in particular. It is seen that if any hospital fulfils expectations of patients, patients are more likely to stay with that particular service provider for a longer time23. 23 Patient satisfaction is also the desired outcome of any hospital6. Therefore it would be beneficial to use a patient expectation survey to plan outpatient services and sensitize physicians about expectations of patients, to ensure a higher chance of patient satisfaction. Such an approach has also been found to be a cost-effective method for reaching large markets13. This would be a desirable step in marketing the hospital as a responsive organization. Patient expectation surveys will lead to a evidence-based and rational use of scarce resources However, it would be best to use such a patient expectation survey in conjunction with a patient satisfaction survey to complete the ‘before' and ‘after' picture. It can reasonably be concluded that in the current competitive healthcare scenario, patient satisfaction surveys in respect of a particular service can be an important market information and research tool in the hands of contemporary hospital administrators.